title: Subcutaneous emphysema as the first relevant clinical sign of complicated tubercular lymph node disease in a child.
abstract: BACKGROUND
  Children make up a significant proportion of the global tuberculosis (TB) caseload, and experience considerable TB-related morbidity and mortality. Unfortunately, it is not easy to diagnose TB in the first years of life because of the diversity of its clinical presentation and the non-specific nature of most of its symptoms.
  
  
  METHODS
  A 26-month-old male child was admitted to hospital because of the sudden onset of rapidly increasing swelling of the neck, face and upper trunk a few hours before. Upon admission, his temperature was 36.5°C, pulse rate 120/min, respiratory rate 36/min, and O2 saturation 97% in air. Palpation revealed subcutaneous emphysema (SE) over the swollen skin areas, and an examination of the respiratory system revealed crepitations in the left part of the chest without any significant suggestion of mediastinal shift. Chest radiography showed enlargement of the left lung hilum with pneumomediastinum and diffuse SE. Bronchoscopy was carried out because of the suspicion that the SE may have been due to the inhalation of a peanut. This excluded the presence of a foreign body but showed that the left main bronchus was partially obstructed with caseous material and showed significant signs of granulomatous inflammation on the wall. Contrast-enhanced computed tomography of the lungs confirmed the SE and pneumomediastinum, and revealed bilateral hilum lymph node disease with infiltration of the adjacent anatomical structure and a considerable breach in the left primary bronchus wall conditioning the passage of air in the mediastinum and subcutaneous tissue. As a tuberculin skin test and polymerase chain reaction for Mycobacterium tuberculosis on bronchial material and gastric aspirate were positive, a diagnosis of TB was made and oral anti-TB therapy was started, which led to the elimination of M. tuberculosis and a positive clinical outcome.
  
  
  CONCLUSIONS
  This is the first case in which SE was the first relevant clinical manifestation of TB and arose from infiltration of the bronchial wall secondary to caseous necrosis of the hilum lymph nodes. Physicians should be aware of the fact that SE is one of the possible initial signs and symptoms of early TB infection, and act accordingly.
authors.affiliation: Pediatric Clinic 1, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milan, Italy. susanna.esposito@unimi.it.
authors.forename: Susanna
authors.initials: S
authors.lastname: Esposito
authors.forename: Alberto
authors.initials: A
authors.lastname: Giannini
authors.forename: Pietro
authors.initials: P
authors.lastname: Biondetti
authors.forename: Nicola
authors.initials: N
authors.lastname: Bonelli
authors.forename: Mario
authors.initials: M
authors.lastname: Nosotti
authors.forename: Samantha
authors.initials: S
authors.lastname: Bosis
authors.forename: Edoardo
authors.initials: E
authors.lastname: Calderini
authors.forename: Nicola
authors.initials: N
authors.lastname: Principi
mesh_terms: D002675:Child, Preschool; D006801:Humans; D008297:Male; D009169:Mycobacterium tuberculosis / Q000235:genetics / Q000302:isolation & purification; D013352:Subcutaneous Emphysema / Q000175:diagnosis / Q000209:etiology*; D014388:Tuberculosis, Lymph Node / Q000150:complications* / Q000382:microbiology